Strangers to Ourselves review by Rachel Aviv – redefining mental illness | Books

SShortly after her sixth birthday, Rachel Aviv stopped eating. It was Yom Kippur the previous week and his family members had been observing the traditional fast. Back at school, brimming with remaining “religious energy,” she refused even the tiny portions her teacher put on her plate. “She looked at me intently – I could feel her contemplating who I was, and her focus was exhilarating,” Aviv recalls.

She persisted through dizziness and dehydration, and before long she was admitted to Michigan Children’s Hospital for “dietary deprivation.” In the anorexia unit, the threat of the “feeding tube” hung over every meal – though in his childish imagination it became a terrifying device, a la Willy Wonka: “a huge tube, like a covered slide, in which I would live”.

There were older girls in the unit, including 12-year-old Hava. Attractive and charismatic, she introduced newcomers to calorie counting and exercise rituals. Aviv was watched by nurses for 45 minutes after eating to make sure she didn’t vomit. Until then, she hadn’t even realized that it was possible to vomit on purpose.

Two weeks later, she unexpectedly found herself finishing a meal without realizing it and was allowed to call her parents as a reward. The spell was broken, though to her it felt like “a random choice.” Despite this, the unit psychologist recommended that she be sent to a psychiatric hospital for the next phase of her treatment. Aviv’s mother refused and his illness never returned.

The “sliding door” story that opens this deeply intelligent book – Aviv says she was “recruited for anorexia, but the disease never became a ‘career'” – suggests that what will follow is a brutal repudiation of the medical model that almost demanded it. , a warning about the dangers of overdiagnosis, a skeptical view of disease as identity. The fact that she avoids these easy positions testifies to the open and inquisitive nature of her investigation. If there’s one point she wants to make, it’s that the stories we tell about distress, and unusual, sometimes destructive behavior, are just that – stories. They can be beneficial, oppressive or something in between; they may work primarily for our benefit, or for others. They can also, in the same person, change or intertwine. Beyond them lies something elusive: the initial thoughts and feelings, “when a person’s anguish, loneliness, and disorientation had not yet been given a name and a receptacle.” Aviv’s contact with not quite anorexia has kept her in touch with this incomplete state of mind, and so she finds herself “searching for the gap between people’s experiences and the stories that organize their suffering. , sometimes defining the course of their lives”.

This research results in a set of superbly written portraits of five people who find themselves at the crossroads of alternative explanations for their pain. From the 1970s, there is Ray, who embodies the clash between psychoanalysis and psychopharmacology. A highly motivated doctor turned businessman, his wife and sons leave him after years of ignorance. Locked in a catastrophic cycle of regret and increasingly unable to function, he is persuaded to check himself into a mental institution. But at Chestnut Lodge, Maryland, only conversation is on the menu. His doctor prescribes a rigorous treatment program for him and proclaims that if Ray were to “stay in treatment for five or 10 years, he could get a good result from it”. Drug treatment, on the other hand, “might provide some symptomatic relief, but it won’t be anything solid. [after] that he can say ‘Hey, I’m a better man, I can tolerate feelings.’

Ray develops a certain insight, even adopting psychoanalytic language: he exclaims in his diary “I am lying halfway between Eros and Thanatos”, writing that he has the impression that “I am being held up a mirror”. . But the process is slow and exhausting. Frustrated, his mother has him transferred to Silver Hill, where antidepressants are the order of the day. After three weeks, he saw a breakthrough: “Something is happening to me,” he told his nurse. For the first time, he feels real sadness at the loss of his family. Gradually, his sense of humor and his interest in his hobbies return. He was released after three months and decided to sue Chestnut Lodge for malpractice. The resulting case is billed as the “Roe vs. Wade of psychiatry”.

Then there is Bapu, the Indian woman who stands at the forefront of mysticism and illusion. After marrying into a hostile family, she turns to religion to ease her loneliness, praying for several hours a day in the only space in the house she can call her own, essentially a small closet. The 16th century poetess Mirabai, who turned her back on her husband and family, believing she was married to Lord Krishna, becomes her role model. Bapu flees to a temple, only to be found and sent to a mental hospital.

There’s the deeply touching story of Naomi, whose madness could be seen as a rational reaction to a relentlessly racist world. African-American from Chicago, she survived a childhood of extreme deprivation only to be plagued by a constant sense of persecution and hatred. In 2003, terrified that the end of the world was imminent and that she and her family were about to be arrested and killed as “undesirables”, she jumped from a bridge with her two children in her arms. . One of them dies. Juries in this part of the world almost always reject insanity defenses, and Naomi is sent to prison for 15 years.

There’s Laura, who comes closest to what you might call the psychiatric patient as a lifestyle choice. She’s an overachiever from golden Greenwich, Connecticut, whose illness sometimes offers her a break from the high expectations of her milieu. The drugs serve to keep her at the top of her game: Harvard student, college squash player. At this point, Aviv inserts the story of her own re-entry into the orbit of psychiatry. After a bout of anxiety, he was prescribed Lexapro for six months. Six months turns into 10 years, during which she repeatedly tries to quit the antidepressant, but feels less herself — or less of the outgoing, spontaneous self the drug had allowed her to inhabit. She discovers that “to continue as the person I had become, I needed a drug”. We return to Laura, who finds herself the victim of a “prescription cascade”, with new pills added to deal with the side effects of the old ones. Eventually, she decides she’s had enough and becomes an online evangelist for drug abstinence. Aviv, meanwhile, makes an uneasy peace with her augmented personality.

None of these stories offer simple answers. Antidepressants don’t solve all of Ray’s problems, and his regrets and self-obsession follow him to his grave. Bapu is not a holy woman colonized by a foreign psychiatric tradition: as her daughter says after visiting her room at the Guruvayur temple, her wall covered with incomprehensible scrawls: “the person I saw – it was not a spiritual person. He was a person who was quite lost. Naomi is not simply a victim of structural oppression, an analysis that risks becoming “another version of the rejection of individual accounts of black pain”. And Laura’s vehement anti-drug stance after going off every last pill is, according to Aviv, just another way to make drugs the be-all and end-all of mental health conversations.

And Havana? By the time Aviv reunites with his old hospital buddy, it’s too late. Plagued by a chronic eating disorder, she had died in her sleep in her mid-40s, just weeks earlier. Despite everything, she had found happiness with a loving partner and kept a vivid and insightful diary for many years. It’s something Hava had in common with each of the other characters, and it’s what allows Aviv to create such subtle biographies. It also makes a crucial point for her: despite the rival camps and competing explanations, the conundrum of mental illness is not that difficult – its causes are “an interaction between biological, genetic, psychological and environmental factors”. But it can be unfathomably complex as it unfolds in people’s lives. Ultimately, as Aviv’s remarkable book shows, only their own stories can make sense of it.